Informed Consent for Assessment and Screening Adult-1
This document contains important information about our services and operation policies. Please read it carefully, and note any questions you might have so that you can discuss them with your clinician. When you sign this document, by electronic (e-sign: full name in conjunction with providing specific identifying information) or physical signature, it will represent an agreement between you and Pursuit of Happiness.
* Required
Section A
Please place your initials in the box below indicating that you have thoroughly reviewed and understand the above disclosure. *
Your answer
Section B
I understand that as a client of Pursuit of Happiness I will be undergoing a screening questionnaire. This questionnaire will be reviewed by a Licensed Professional Counselor (LPC), and I will receive feedback based on my responses. I understand that this screening will not be used for diagnostic purposes, but will be used to determine a recommendation made by the LPC.

I understand that the results of the screening may be used for research purposes, but in the context of research, no personally identifying information will be used.

I understand that due to the nature of the personal questions involved in psychological screening, emotional distress may result. I may interrupt or discontinue the testing process at any time.

I understand that services will be provided by a Licensed Professional Counselor (LPC). Information shared with my LPC is confidential and no information will be released without my consent other than to the Director of Mental Health Services of Pursuit of Happiness. In all other circumstances, consent to release information is given through written authorization signed by me. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which, according to Texas statutes, include the following:

When there is imminent risk of danger to myself or others, clinician is ethically bound to take appropriate necessary steps to prevent such danger.
When there is a suspicion that a child, elderly, or someone who cannot otherwise protect themselves from physical or sexual abuse, clinician is legally required to take steps to protect the victim, and to inform the proper authorities.
When a valid court order is issued for specific medical records, or if records are subpoened, the clinician and the agency are bound by law to comply with such requests.

I understand that all services are provided by Licensed Professional Counselors (LPC) who practice with a license governed by the Texas State Board of Examiners of Professional Counselors, which is a division of Texas Department of State Health Services, and that all therapists with Pursuit of Happiness are independent contractors.

I understand that if I cancel or do not show up to my appointment, and do not give at least 24 hours notice, I will not receive a refund, and I will be responsible for the payment of that session. I understand that cancellations made up to three days in advance are eligible for a refund of fifty percent and that I am responsible for fifty percent of the regular payment, and cancellations greater than three days are eligible for a full refund. I understand that all refunds for cancellations of appointments are at the sole discretion of Pursuit of Happiness.

I understand that Pursuit of Happiness operates a limited number of hours per week. If I have an emergency situation, I may leave a message on my clinician’s voicemail to try to schedule an immediate appointment. Unless otherwise discussed with my clinician, on nights and weekends I will contact my family physician or the nearest emergency room and ask for the psychologist/psychiatrist on call. PURSUIT OF HAPPINESS DOES NOT OFFER 24 HOUR CARE.

If I have any questions regarding this consent form or about the services offered by Pursuit of Happiness, I may discuss them with my therapist. I have read and understand the above. I consent to participate in the screening offered to me by Pursuit of Happiness.

Place initials in the box below. *
Your answer
Section C
Please type FULL NAME in box below. *
Your answer
Current Month *
Today's Date *
Current Year *
ex: 2010, 2012, etc
Your answer
Please save or print a copy of this informed consent for your records.
Never submit passwords through Google Forms.
This form was created inside of Pursuit of Happiness. Report Abuse - Terms of Service